Tag Archives: on-call

Resuscitation, Trauma Center

In-House Trauma Surgeon Call – Worth It?

Nearly universally, trauma surgeons at Level I and Level II trauma centers must be at the bedside within 15 minutes of the patient’s arrival. For most, this means that they must take in-house call. This requirement has been on the books for decades. It’s just the way we do it. And that makes it fair game to examine whether it is worth the extra work.

An older prospective comparison of two Level I centers (1990) reported no difference in care timing or clinical outcomes when surgeons taking call from home lived within 15 minutes of the hospital, received reliable paging activation, and responded promptly (reference 1). Unfortunately, these days, most surgeons cannot get to the hospital within 15 minutes at night unless they arrive in their pajamas.

A large 2003 retrospective study found no difference in mortality, time to OR, CT timing, or length of stay. However, this study depended on the presence of senior surgical residents in-house to provide initial care for the trauma patient until the attending surgeon arrived (reference 2).

The best study we have so far comes from a systematic review and meta-analysis by a trauma group in the Netherlands. It included 16 observational studies in the systematic review and 8 studies in the meta-analysis, involving nearly 65,000 trauma patients (reference 3). All papers compared patients treated by in-house surgeons with those treated by surgeons on call off campus. They only looked at the impact of the coverage model on mortality.

Here are the factoids:

  • The meta-analysis showed a statistically significant risk-reduction of 14% in the patients managed by an in-house surgeon
  • There was a further mortality reduction noted in more recent papers, with an overall reduction of 17%
  • When five of the 16 papers identified as having severe bias were removed, the mortality decreased even further by a total of 19%
  • Mortality was reduced at low-volume centers with in-house surgeons by 15%

Bottom line: I have been taking in-house trauma call for 40 years. It was interesting and exciting at first, but began to wear on me over time. My impression was that in 95% of the patients that I treated, the survival die was already cast. They were destined to live or die, and little that I could do would change that. However, that remaining 5% included the patients that I would look at afterward and think to myself, “If I hadn’t been here, we would have lost them.” 

This review article bears this out, but it only addresses mortality rates. I’m fairly certain that several other, more subtle processes are also improved. For now, trauma patients who need the highest level of care clearly benefit from having a trauma surgeon at their side upon arrival. Is taking call in-house the answer? If arriving at the bedside within the 15-minute limit can be accomplished from home with a short drive time (and sleeping in scrubs), the results should be the same. The key is having the surgeon present and ready to control life-threatening hemorrhage within minutes of their arrival. However, in most urban and suburban centers, the only way to guarantee this is to stay in the hospital.

References:

  1. In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999 Apr;46(4):535-40; discussion 540-2. doi: 10.1097/00005373-199904000-00001. PMID: 10217215.
  2. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma. 2003 Jul;55(1):20-5. doi: 10.1097/01.TA.0000071621.39088.7B. PMID: 12855876.
  3. In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021 Aug 1;91(2):435-444. doi: 10.1097/TA.0000000000003226. PMID: 33852558.
General

Surgeons Who Operate Post-Call

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Fatigue is a big deal for trauma professionals. I previously devoted a week of posts to detailing research on fatigue, and dedicated the June 2012 Trauma MedEd newsletter to the topic. So I just reviewed a paper suggesting that it might not be such a big deal for attending (consultant) surgeons who operate after they’ve been on call.

The whole idea came about because residents in the US (registrars) have had restrictions to their work hours in place for 10 years, limiting them to only 80 hours per week. Yet the attending physicians, who are older and more likely to show the effects of fatigue, have no such limits. They can work as long as they want. Maybe their greater experience or long-established habits of occasional sleep deprivation are protective?

The group in Memphis looked at this phenomenon, performing a retrospective review of patients operated on by surgeons post-call and those who were not. They looked at 737 patients over 3.5 years, of which 15% were performed by post-call staff surgeons. Here are the key points:

  • Only cholecystectomy, hernia and intestinal procedures for bowel obstruction, ischemia or bleeding were evaluated
  • The authors used complications and readmission as outcomes to monitor
  • Complications occurred in about 13% of both post-call and no-call groups. No difference.
  • Readmissions within 30 days occurred in about % of both groups. Again, no difference.

So it looks like it’s okay to operate after the surgeon’s been up at night, right? Wrong! This is another perfect example of why it’s so important to read the whole paper, not just the abstract. Major problems:

  • The actual amount of sleep or fatigue levels are not quantified, so it’s a mix.
  • It’s a teaching hospital, so the surgeons always operate with a trainee at some level. The residents either do the work, or can “double check” the surgeon’s work to prevent any significant errors.
  • Complications and readmission rates are very crude indicators of error. Only the most egregious problems would manifest as one of these.

Bottom line: There is plenty of non-medical literature out there that shows that fatigue is bad (aviation, trucking, marine operations). And as much as we’d like to believe it, surgeons and other physicians are in no way immune to its effects. What this paper really showed is that if you are supervising a well-rested trainee and looking at outcomes that aren’t directly related to fatigue, everything looks great! It’s not, and all trauma professionals need to be aware of the fact that, even though they feel invincible and that they can do anything after sleep deprivation, it’s just their fatigue talking. Protect your patients and make sure that everyone who takes care of them is in tip-top shape.

Reference: Outcomes of operations performed by attending physicians after overnight trauma shifts. Journal Am Coll Surg, in press 11 Jan 2013.

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General

A Shortage of On-call Surgical Specialists to EDs?

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The results of a survey published this month details problems caused by the lack of surgical specialists on call to emergency departments. It was conducted by the Robert Wood Johnson Clinical Scholars program and Yale University. They sent the survey to ED directors at 715 randomly selected hospitals around the country. The response rate was very good, with 62% returning their surveys.

An overwhelming majority (74%) of EDs indicated that they experience inadequate call coverage by surgical specialists. Notable comparisons included:

  • Teaching hospital (68% had problems) vs non-teaching hospital (78%)
  • Level I trauma center (60% had problems) vs Level II trauma center (59%) vs Level III trauma center (77%)

Almost two thirds of respondents said they had lost 24/7 coverage of at least one surgical specialty within the last 4 years. Hospitals in metropolitan areas were more likely to experience this problem, as were hospitals in the Northeast and South, compared to the West and the Midwest.

As you can imagine, coverage issues can cause larger problems. Nearly a quarter of hospitals either lost or downgraded their trauma center level due to lack of surgical specialist coverage. And 27% reported patients leaving before they could be seen by the specialist.

The percentage of hospitals with no coverage or problem coverage by surgical specialty was as follows:

  • General surgery – 36%
  • Trauma surgery – 64%
  • Neurosurgery – 75%
  • Plastics – 81%
  • Hand – 80%
  • Ortho – 50%

It is becoming apparent that there are limits to the amount of on-call specialty coverage that money can buy. Careful coordination and regionalization may offer aid to some centers, but we need to look critically at strategies in use that work and find ways to disseminate them to maintain the best emergency care possible.

Reference: The Shortage of On-call Surgical Specialist Coverage: A National Survey of Emergency Department Directors. Academic Emerg Med 17(12):1374-82, Dec 2010.